Community-acquired Septic Shock Research Articles

Social Determinants of Health and Health-Related Quality of Life following Pediatric Septic Shock: Secondary Analysis of the Life After Pediatric Sepsis Evaluation Dataset, 2014-2017.

Social determinants of health (SDOH) are associated with disparities in disease severity and in-hospital outcomes among critically ill children. It is unknown whether SDOH are associated with later outcomes. We evaluated associations between SDOH measures and mortality, new functional morbidity, and health-related quality of life (HRQL) decline among children surviving septic shock. Secondary analysis of the Life After Pediatric Sepsis Evaluation (LAPSE) prospective cohort study was conducted between 2014 and 2017. Twelve academic U.S. PICUs were involved in the study. Children younger than 18 years with community-acquired septic shock were involved in the study. None. We assessed associations between race, ethnicity, income, education, marital status, insurance, language, and home U.S. postal code with day 28 mortality, new functional morbidity at discharge per day 28, and HRQL decline using logistic regression. Of 389 patients, 32% (n = 98) of families had household income less than $50,000 per year. Median Pediatric Risk of Mortality (PRISM) score was 11 (interquartile range 6, 17). We found that English language and Area Deprivation Index less than 50th percentile were associated with higher PRISM scores. Mortality was 6.7% (n = 26), new functional morbidity occurred in 21.8% (n = 78) of patients, and HRQL decline by greater than 10% occurred in 31.0% of patients (n = 63). We failed to identify any association between SDOH measures and mortality, new functional morbidity, or HRQL decline. We are unable to exclude the possibility that annual household income greater than or equal to $50,000 was associated with up to 81% lesser odds of mortality and, in survivors, more than three-fold greater odds of HRQL decline by greater than 10%. In this secondary analysis of the 2014-2017 LAPSE dataset, we failed to identify any association between SDOH measures and in-hospital or postdischarge outcomes following pediatric septic shock. This finding may be reflective of the high illness severity and single disease (sepsis) of the cohort, with contribution of clinical factors to functional and HRQL outcomes predominating over prehospital and posthospital SDOH factors.

Association of Sex and Age with Mortality and Health-Related Quality of Life in Children with Septic Shock: A Secondary Analysis of the Life After Pediatric Sepsis Evaluation.

Introduction: Sepsis is more common in males than females, but whether outcomes differ by sex in various pediatric age groups is unclear. The Life After Pediatric Sepsis Evaluation (LAPSE) was a multicenter prospective cohort study that evaluated health-related quality of life (HRQL) in children after community-acquired septic shock. In this secondary analysis, we evaluated whether male children are at increased risk of mortality or long-term decline in HRQL than female children by age group. Methods: Children (1 month-18 years) with community-acquired septic shock were recruited from 12 pediatric intensive care units in the U.S. Data included sex, age group (<1 year, 1-<13 years, 13-18 years), acute illness severity (acute organ dysfunction and inflammation), and longitudinal assessments of HRQL and mortality. Persistent decline in HRQL was defined as a 10% decrease in HRQL comparing baseline to 3 months following admission. Male and female children were stratified by age group and compared to evaluate the difference in the composite outcome of death or persistent decline in HRQL using the Cochran-Mantel-Haenszel test. Results: Of 389 children, 54.2% (n = 211) were male. Overall, 10% (21/211) of males and 12% (22/178) of females died by 3 months (p = 0.454). Among children with follow-up data, 41% (57/138) of males and 44% (48/108) of females died or had persistent decline in HRQL at 3 months (p = 0.636), with no observed difference by sex when stratified by age group. There was no significant difference in acute illness severity between males and females overall or stratified by age group. Conclusions: In this secondary analysis of the LAPSE cohort, HRQL, and mortality were not different between male and female children when stratified by age group. There were no significant differences by sex across multiple measures of illness severity or treatment intensity.

Change in Functional Status During Hospital Admission and Long-Term Health-Related Quality of Life Among Pediatric Septic Shock Survivors.

To investigate whether change in functional status from pre-hospitalization baseline to hospital discharge is associated with long-term health-related quality of life (HRQL) among children surviving septic shock. Secondary analysis of Life After Pediatric Sepsis Evaluation (LAPSE), a prospective cohort study of children with community-acquired septic shock, enrolled from January 2014 to June 2017. Twelve U.S. academic PICUs. Children, 1 month to 18 years, who survived to hospital discharge and had follow-up data for HRQL at 3 and/or 12 months. None. Functional Status Scale (FSS) was assessed around enrollment to ascertain baseline status (pre-hospitalization) and at 28 days or hospital discharge. Two measures of HRQL were utilized: children with significant development delay were measured with the Functional Status II-R (FSII-R); typically, developing children were measured with the Pediatric Quality of Life Inventory (PedsQL). Each group was analyzed separately with multivariable regression modeling to determine the association between change in FSS from baseline to day 28 and HRQL at 3 and 12 months from PICU admission. Of the original 389 LAPSE participants, 224 (58%) are included. Among children with developmental delay ( n = 88), worsened FSS was associated with lower FSII-R at 3 months from PICU admission (-2.02; 95% CI, -3.34 to -0.0.71; p = 0.003), but not 12 months. Among developmentally typical children ( n = 136), worsened FSS was associated with lower PedsQL at both 3 and 12 months. Developmentally typical children with a neurologic insult during the PICU stay had the largest decrement in PedsQL at 12 months (-14.04 mo; 95% CI, -22.15 to -5.94 mo; p < 0.001). However, worsened FSS remained associated with poor HRQL-PedsQL at 3 and 12 months, after controlling for neurologic events (both p < 0.001). Change in FSS during hospitalization for septic shock is associated with long-term reductions in HRQL and could serve as a useful tool for identifying children at risk for this sequela.

Fluid Balance and Its Association With Mortality and Health-Related Quality of Life: A Nonprespecified Secondary Analysis of the Life After Pediatric Sepsis Evaluation.

To evaluate the association between fluid balance (FB) and health-related quality of life (HRQL) among children at 1 month following community-acquired septic shock. Nonprespecified secondary analysis of the Life After Pediatric Sepsis Evaluation. FB was defined as 100 × [(cumulative PICU fluid input - cumulative PICU fluid output)/PICU admission weight]. Three subgroups were identified: low FB (< 5%), medium FB (5%-15%), and high FB (> 15%) based on cumulative FB on days 0-3 of ICU stay. HRQL was measured at ICU admission and 1 month after using Pediatric Quality of Life Inventory 4.0 Generic Core or Infant Scales or the Stein-Jessop Functional Status Scale. The primary outcome was a composite of mortality or greater than 25% decline in HRQL 1 month after admission compared with baseline. Twelve academic PICUs in the United States. Critically ill children between 1 month and 18 years, with community-acquired septic shock who survived to at least day 4. None. Two hundred ninety-three patients were included of whom 66 (23%) had low FB, 127 (43%) had medium FB, and 100 (34%) had high FB. There was no difference in Pediatric Risk of Mortality Score 3 (median 11 [6, 17]), age (median 5 [1, 12]), or gender (47% female) between FB groups. After adjusting for potential confounders and comparing with medium FB, higher odds of mortality or greater than 25% HRQL decline were seen in both the low FB (odds ratio [OR] 2.79 [1.20, 6.57]) and the high FB (OR 2.16 [1.06, 4.47]), p = 0.027. Compared with medium FB, low FB (OR 4.3 [1.62, 11.84]) and high FB (OR 3.29 [1.42, 8.00]) had higher odds of greater than 25% HRQL decline. Over half of the children who survived septic shock had low or high FB, which was associated with a significant decline in HRQL scores. Prospective studies are needed to determine if optimization of FB can improve HRQL outcomes.

Nangibotide for precision immunomodulation in septic shock and COVID-19

Nangibotide for precision immunomodulation in septic shock and COVID-19

Descriptive statistics and risk factor analysis of children with community-acquired septic shock

BackgroundChildren with community-acquired septic shock can rapidly deteriorate and die in acute-care hospitals. This study aimed to describe the mortality, timing, and risk factors in children with community-acquired septic shock.MethodsThis is a retrospective cohort study using a national inpatient database in Japan. The study population included children (age < 20 years) who were admitted to acute-care hospitals with a diagnosis of sepsis from July 2010 to March 2020, who were treated with antibiotics, and who were supported with vasoactive drugs within three days of hospitalization. We used a Cox proportional-hazards regression model to identify risk factors for earlier death.ResultsAmong 761 eligible children, the median age was 3 (interquartile range, 0–11) years and 57.2% had underlying conditions. Among these, 67.1% were admitted to accredited intensive care units within three days of hospitalization and 38.6% were transported from other hospitals. The median hospital volume, defined as the number of eligible children in each hospital over the study period, was 4 (interquartile range, 2–11). Overall, 244 children died (in-hospital mortality rate, 32.1%). Among them, 77 (31.6%) died on the first day, and 156 (63.9%) died within three days of hospitalization. A Cox proportional-hazards regression model showed that earlier death was associated with lower hospital volume and age 1–5 years, whereas it was inversely associated with admission to an accredited intensive care unit and transport from other hospitals. Among 517 survivors, 178 (34.4%) were discharged with comorbidities.ConclusionsChildren with community-acquired septic shock had high mortality, and early death was common. Our findings may warrant future efforts to enhance the quality of initial resuscitation for sepsis in low-volume hospitals and to ensure a healthcare system in which children with sepsis can be treated in accredited intensive care units.

Application of initial anti-infectives and trends in children with septic shock

Objective: To investigate the pathogen composition, initial anti-infectives and pathogen coverage, and trends over the last 5 years in children with septic shock in pediatric intensive care unit (PICU). Methods: The single-center retrospective study included 257 children with septic shock who were admitted to PICU of Beijing Children's Hospital, Capital Medical University from 2017 to 2021. The causitive pathogen composition, initial use of anti-infective drugs, pathogen coverage, and changes in recent years were analyzed. The children were divided into sufficient and insufficient coverage groups according to whether the pathogen were sufficiently covered by initial anti-infectives; community-and hospital-acquired groups; and with and without underlying disease groups. T test, rank-sum test and Chi-square test were used for comparison between the groups to investigate the differences in pathogen, treatment and prognosis. Results: A total of 257 septic shock children were included, with 162 males and 95 females, aged 36 (12, 117) months. The pathogen positive rate was 64.6% (166/257) and the in-hospital mortality was 27.6% (71/257). In the 208 pathogen-positive samples, bacteria was the most common (57.7%, 120/208) with G-negative bacteria predominating (55.8%, 67/120), followed by viruses (26.0%, 54/208). Nearly 99.2% (255/257) of the children were treated with antibacterial at the beginning, of whom 47.1% (121/257) were treated with carbapenems combined with vancomycin or linezolid. The proportion of 3 or more antibacterial combinations was higher in children with underlying diseases and hospital-acquired septic shock than in those without underlying disease or community-acquired septic shock (27.4% (49/179) vs. 14.1% (11/78), 29.4% (52/177) vs. 10.0% (8/80), χ2=5.35,11.56,all P<0.05). The proportion of initial combination of carbapenem and vancomycin or linezolid reduced from 52.5% (21/40) to 41.3% (19/46), and of adequate pathogen coverage increased from 40.0% (16/40) to 58.7% (27/46) in the last five years. Conclusions: The initial use of antibacterial drugs is common in children with septic shock in PICU, especially in those with hospital-acquired septic shock and underlying diseases. In recent years, antimicrobial combinations have decreased, but the pathogen coverage has improved, indicating that drug selection is more reasonable and accurate.

Association Between Preexisting Heart Failure With Reduced Ejection Fraction and Fluid Administration Among Patients With Sepsis

Intravenous fluid administration is recommended to improve outcomes for patients with septic shock. However, there are few data on fluid administration for patients with preexisting heart failure with reduced ejection fraction (HFrEF). To evaluate the association between preexisting HFrEF, guideline-recommended intravenous fluid resuscitation, and mortality among patients with community-acquired sepsis and septic shock. A cohort study was conducted of adult patients hospitalized in an integrated health care system from January 1, 2013, to December 31, 2015, with community-acquired sepsis and preexisting assessment of cardiac function. Follow-up occurred through July 1, 2016. Data analyses were performed from November 1, 2020, to August 8, 2022. Preexisting heart failure with reduced ejection fraction (≤40%) measured by transthoracic echocardiogram within 1 year prior to hospitalization for sepsis. Multivariable models were adjusted for patient factors and sepsis severity and clustered at the hospital level to generate adjusted odds ratios (aORs) and 95% CIs. The primary outcome was the administration of 30 mL/kg of intravenous fluid within 6 hours of sepsis onset. Secondary outcomes included in-hospital mortality, intensive care unit admission, rate of invasive mechanical ventilation, and administration of vasoactive medications. Of 5278 patients with sepsis (2673 men [51%]; median age, 70 years [IQR, 60-81 years]; 4349 White patients [82%]; median Sequential Organ Failure Assessment score, 4 [IQR, 3-5]), 884 (17%) had preexisting HFrEF, and 2291 (43%) met criteria for septic shock. Patients with septic shock and HFrEF were less likely to receive guideline-recommended intravenous fluid than those with septic shock without HFrEF (96 of 380 [25%] vs 699 of 1911 [37%]; P < .001), but in-hospital mortality was similar (47 of 380 [12%] vs 244 of 1911 [13%]; P = .83). In multivariable models, HFrEF was associated with a decreased risk-adjusted odds of receiving 30 mL/kg of intravenous fluid within the first 6 hours of sepsis onset (aOR, 0.63; 95% CI, 0.47-0.85; P = .002). The risk-adjusted mortality was not significantly different among patients with HFrEF (aOR, 0.92; 95% CI, 0.69-1.24; P = .59) compared with those without, and there was no interaction with intravenous fluid volume (aOR, 1.00; 95% CI, 0.98-1.03; P = .72). The results of this cohort study of patients with community-acquired septic shock suggest that preexisting HFrEF was common and was associated with reduced odds of receiving guideline-recommended intravenous fluids.

Comparison between hospital- and community-acquired septic shock in children: a single-center retrospective cohort study

BackgroundWe explored the differences in baseline characteristics, pathogens, complications, outcomes, and risk factors between children with hospital-acquired septic shock (HASS) and community-acquired septic shock (CASS) in the pediatric intensive care unit (PICU).MethodsThis retrospective study enrolled children with septic shock at the PICU of Beijing Children’s Hospital from January 1, 2016, to December 31, 2019. The patients were followed up until 28 days after shock or death and were divided into the HASS and CASS group. Logistic regression analysis was used to identify risk factors for mortality.ResultsA total of 298 children were enrolled. Among them, 65.9% (n = 91) of HASS patients had hematologic/oncologic diseases, mainly with Gram-negative bacterial bloodstream infections (47.3%). Additionally, 67.7% (n = 207) of CASS patients had no obvious underlying disease, and most experienced Gram-positive bacterial infections (30.9%) of the respiratory or central nervous system. The 28-day mortality was 62.6% and 32.7% in the HASS and CASS groups, respectively (P < 0.001). Platelet [odds ratio (OR) = 0.996, 95% confidence interval (CI) = 0.992–1.000, P = 0.028], positive pathogen detection (OR = 3.557, 95% CI = 1.307–9.684, P = 0.013), and multiple organ dysfunction syndrome (OR = 10.953, 95% CI = 1.974–60.775, P = 0.006) were risk factors for 28-day mortality in HASS patients. Lactate (OR = 1.104, 95% CI = 1.022–1.192, P = 0.012) and mechanical ventilation (OR = 8.114, 95% CI = 1.806–36.465, P = 0.006) were risk factors for 28-day mortality in patients with CASS.ConclusionsThe underlying diseases, pathogens, complications, prognosis, and mortality rates varied widely between the HASS and CASS groups. The predictors of 28-day mortality were different between HASS and CASS pediatric patients with septic shock.

Association of Illness Severity With Family Outcomes Following Pediatric Septic Shock.

IMPORTANCE:It is unknown which families are at risk for poor outcomes following a child’s critical illness.OBJECTIVES:To evaluate if pediatric septic shock severity is associated with caregiver distress and family dysfunction throughout the year postadmission and if caregiver outcomes are associated with child health-related quality of life (HRQL).DESIGN, SETTING, AND PARTICIPANTS:Secondary analysis of the Life After Pediatric Sepsis Evaluation prospective cohort study among children less than 18 years old with community-acquired septic shock requiring vasoactive-inotropic support and invasive or noninvasive ventilation in 12 academic U.S. PICUs.MAIN OUTCOMES AND MEASURES:Caregivers reported personal psychologic distress (Brief Symptom Inventory), family functioning (Family Assessment Device), and child HRQL (Pediatric Quality of Life Inventory, Functional Status II-Revised) at baseline and 1, 3, 6, and 12 months following PICU admission.RESULTS:Among 276 caregivers, psychologic distress prevalence initially decreased then rose to 15.3%, whereas prevalence of family dysfunction increased steadily to 30.9% at 12 months. On multivariable logistic regression adjusting for patient age, medical complexity, and immunosuppression, higher Pediatric Risk of Mortality and vasoactive-inotropic scores and longer PICU and hospital stay were associated with greater caregiver distress at 1 month. Higher Pediatric Logistic Organ Dysfunction (PELOD) score, longer ventilation, and longer PICU stay were associated with lower odds of family dysfunction at 1, 3, and 6 months (average PELOD vs new 6-mo dysfunction: odds ratio [OR], 0.73 [95% CI, 0.55–0.96]). Caregiver distress was associated with child HRQL decline from baseline to 1 month (OR, 2.92 [1.27–6.75]), 3 months (OR, 2.34 [1.01–5.42]), and 12 months (OR, 3.94 [1.54–10.06]).CONCLUSIONS AND RELEVANCE:Family dysfunction becomes increasingly prevalent over the year following pediatric septic shock and is less likely following higher severity illness. Caregiver psychologic distress is associated with worse child HRQL. Both patients and families may benefit from ongoing psychosocial support following survival from pediatric septic shock.

The Association of Early Corticosteroid Therapy With Clinical and Health-Related Quality of Life Outcomes in Children With Septic Shock.

Corticosteroids are commonly used in the treatment of pediatric septic shock without clear evidence of the potential benefits or risks. This study examined the association of early corticosteroid therapy with patient-centered clinically meaningful outcomes. Subsequent cohort analysis of data derived from the prospective Life After Pediatric Sepsis Evaluation (LAPSE) investigation. Outcomes among patients receiving hydrocortisone or methylprednisolone on study day 0 or 1 were compared with those who did not use a propensity score-weighted analysis that controlled for age, sex, study site, and measures of first-day illness severity. Twelve academic PICUs in the United States. Children with community-acquired septic shock 1 month to 18 years old enrolled in LAPSE, 2013-2017. Exclusion criteria included a history of chronic corticosteroid administration. None. Among children enrolled in LAPSE, 352 of 392 met analysis inclusion criteria, and 155 of 352 (44%) received early corticosteroid therapy. After weighting corticosteroid therapy administration propensity across potentially confounding baseline characteristics, differences in outcomes associated with treatment were not statistically significant (adjusted effect or odds ratio [95% CI]): vasoactive-inotropic support duration (-0.37 d [-1.47 to 0.72]; p = 0.503), short-term survival without new morbidity (1.37 [0.83-2.28]; p = 0.218), new morbidity among month-1 survivors (0.70 [0.39-1.23]; p = 0.218), and persistent severe deterioration of health-related quality of life or mortality at month 1 (0.70 [0.40-1.23]; p = 0.212). This study examined the association of early corticosteroid therapy with mortality and morbidity among children encountering septic shock. After adjusting for variables with the potential to confound the relationship between early corticosteroid administration and clinically meaningful end points, there was no improvement in outcomes associated with this therapy. Results from this propensity analysis provide additional justification for equipoise regarding corticosteroid therapy for pediatric septic shock and ascertain the need for a well-designed clinical trial to examine benefit/risk for this intervention.

Is Piperacillin-Tazobactam an Appropriate Empirical Agent for Hospital-Acquired Sepsis and Community-Acquired Septic Shock of Unknown Origin in Australia?

Early appropriate empirical antibiotics are critical for reducing mortality in sepsis. For hospital-acquired sepsis of unknown origin in Australia, piperacillin-tazobactam (TZP) is recommended as an empirical therapy. Anecdotally, some institutions also use TZP for community-acquired septic shock. This narrative review aimed to scrutinise the appropriateness of TZP as an empirical agent for undifferentiated hospital-acquired sepsis and community-acquired septic shock. An online database (Medline) was searched for relevant studies in adults published in the last 10 years. Studies were included if they addressed separately reported clinical outcomes related to a relevant aspect of TZP therapy in sepsis. Of 290 search results, no studies directly addressed the study aim. This review therefore explores several themes that emerged from the contemporary literature, all of which must be considered to fully interrogate the appropriateness of TZP use in this context. This review reveals the paucity and low quality of evidence available for TZP use in sepsis of unclear origin, while demonstrating the urgent need and equipoise for an Australian audit of TZP use in patients with sepsis of unknown origin.

Health Resource Use in Survivors of Pediatric Septic Shock in the United States.

To evaluate postdischarge health resource use in pediatric survivors of septic shock and determine patient and hospitalization factors associated with health resource use. Secondary analyses of a multicenter prospective observational cohort study. Twelve academic PICUs. Children greater than or equal to 1 month and less than 18 years old hospitalized for community-acquired septic shock who survived to 1 year. None. For 308/338 patients (91%) with baseline and greater than or equal to one postdischarge survey, we evaluated readmission, emergency department (ED) visits, new medication class, and new device class use during the year after sepsis. Using negative binomial regression with bidirectional stepwise selection, we identified factors associated with each outcome. Median age was 7 years (interquartile range, 2-13), 157 (51%) had a chronic condition, and nearly all patients had insurance (private [n = 135; 44%] or government [n = 157; 51%]). During the year after sepsis, 128 patients (42%) were readmitted, 145 (47%) had an ED visit, 156 (51%) started a new medication class, and 102 (33%) instituted a new device class. Having a complex chronic condition was independently associated with readmission and ED visit. Documented infection and higher sum of Pediatric Logistic Organ Dysfunction--2 hematologic score were associated with readmission, whereas younger age and having a noncomplex chronic condition were associated with ED visit. Factors associated with new medication class use were private insurance, neurologic insult, and longer PICU stays. Factors associated with new device class use were preadmission chemotherapy or radiotherapy, presepsis Functional Status Scale score, and ventilation duration greater than or equal to 10 days. Of patients who had a new medication or device class, most had a readmission (56% and 61%) or ED visit (62% and 67%). Children with septic shock represent a high-risk cohort with high-resource needs after discharge. Interventions and targeted outcomes to mitigate postdischarge resource use may differ based on patients' preexisting conditions.

Trajectory and Risk Factors of Persistent Decline in Health-Related Quality of Life after Septic Shock in Children with Preexisting Neurologic Disability

AbstractPreexisting neurologic disability is common among children with septic shock. Life After Pediatric Sepsis Evaluation (LAPSE) was a multicenter cohort study that evaluated health-related quality of life (HRQL) in children with community-acquired septic shock. In this secondary analysis of LAPSE, we described the burden, trajectory, and risk factors for reduced HRQL in children with preexisting neurologic disability. Children (1 month–18 years) with community-acquired septic shock were evaluated for HRQL at baseline (reflecting pre-hospitalization status), day 7 and 28, and month 3, 6, and 12 following admission using the Pediatric Quality of Life Inventory or the Stein–Jessop Functional Status Scale. HRQL was expressed as a percentage of baseline scores. Of 365 evaluable children, 133 (36%) had preexisting neurologic disability. Neurologically disabled children had less decline in HRQL at day 7 (median −15% [interquartile range IQR −38, 8] vs. −22% [−51, −3], p = 0.005) and day 28 (4% [−16, 22] vs. −11% [−37, 7], p &lt; 0.001) than those without neurologic disability, and there was no difference in the extent of decline at month 3 (p = 0.241). Using multivariable modeling, higher baseline HRQL (odds ratio [OR] 1.04 [95% confidence interval [CI] 1.00, 1.08], p = 0.027) and acute renal dysfunction (OR 1.08 [1.02, 1.16], p = 0.007) were associated with HRQL less than 90% of baseline at month 3 in neurologically disabled children who survived. Children with preexisting neurologic disability recover to baseline HRQL after septic shock sooner than those without neurologic disability. Higher baseline HRQL and acute renal dysfunction are risk factors for reduced HRQL in neurologically disabled children who survive sepsis.

Clinical risk factors for early mortality in patients with community-acquired septic shock. The importance of adequate source control

ObjectiveTo evaluate the incidence and risk factors for early mortality (EM) in the ICU in patients with community-acquired septic shock (CASS). DesignA retrospective cohort study of patients with CASS admitted to the ICU (2003–2016). SettingICU at a University Hospital in Spain. PatientsAll consecutive patients admitted to the ICU with CASS. InterventionsNone. Main variables of interestCASS was defined according to the Sepsis-3 definitions. EM were defined as occurring within of 72h following ICU admission. A multinomial logistic regression analysis was performed to identify the risk factors associated with early deaths. ResultsDuring the study period, 625 patients met the Sepsis-3 criteria and admitted with CASS. 14.4% of all patients died within the first 72h. Of 161 patients who died in the ICU, 90 (55.9%) died within the first 72h. The percentage of early and late mortality did not vary significantly during the study period. The need and adequacy of source control were significantly lower in patients with EM. In the multivariate analysis, ARDS, non-respiratory infections, bacteremia and severity at admission were variables independently associated with EM. The only factor that decreased EM was adequate source control in patients with infections amenable to source control. ConclusionsThe incidence of EM has remained stable over time, which means that more than half of the patients who die from CASS do so within the first 72h. Infections where adequate source control can be performed have lower EM.

"I Didn't Realize How Hard It Was Going to Be Just Transitioning Back into Life": A Qualitative Exploration of Outcomes for Survivors of Pediatric Septic Shock.

Recovery following pediatric critical illness is multifaceted and complex. While most critically ill children survive, many experience morbidities in physical, emotional, cognitive, and social function. We aimed to deeply explore and describe the multidimensional impact of pediatric septic shock for affected children and their families at the granular level using exploratory qualitative methodology. We performed semistructured telephone interviews of adolescents and caregivers of children admitted with community-acquired septic shock to two tertiary pediatric intensive care units in the United States. Interviews were conducted within two years of hospital admission, and were recorded, transcribed, and analyzed using thematic analysis. Two adolescents and 10 caregivers were interviewed. Participants described meaningful and long-lasting outcomes of septic shock on multiple dimensions of their lives. The adolescents and caregivers described substantial negative consequences on physical health and function which resulted in increased medical complexity and heightened caregiver vigilance. The physical impact led to substantial psychosocial consequences for both the child and family, including social isolation. Most caregivers expressed that septic shock was transformational in their lives, with some caregivers describing posttraumatic growth. This preliminary study provides a novel, granular view of the multidimensional impact of septic shock in pediatric patients and their families. Exploring these experiences through qualitative methodology provides greater insight into important patient and family outcomes. Deeper understanding of these outcomes may support the development of meaningful interventions to improve quality of life for children and their families following critical illness.

Improvement in Health-Related Quality of Life After Community Acquired Pediatric Septic Shock.

Background: Although some pediatric sepsis survivors experience worsening health-related quality of life (HRQL), many return to their pre-illness HRQL. Whether children can improve beyond baseline is not known. We examined a cohort of pediatric sepsis survivors to determine if those with baseline HRQL scores below the population mean could exhibit ≥10% improvement and evaluated factors associated with improvement.Methods: In this secondary analysis of the Life After Pediatric Sepsis Evaluation prospective study, children aged 1 month to 18 years admitted to 12 academic PICUs in the United States with community-acquired septic shock who survived to 3 months and had baseline HRQL scores ≤ 80 (i.e., excluding those with good baseline HRQL to allow for potential improvement) were included. HRQL was measured using the Pediatric Quality of Life Inventory or Stein-Jessop Functional Status Scale.Findings: One hundred and seventeen children were eligible. Sixty-one (52%) had ≥ 10% improvement in HRQL by 3 months. Lower pre-sepsis HRQL was associated with increased odds of improvement at 3 months [aOR = 1.08, 95% CI (1.04–1.11), p < 0.001] and 12 months [OR = 1.05, 95% CI (1.02–1.11), p = 0.005]. Improvement in HRQL was most prevalent at 3 month follow-up; at 12 month follow-up, improvement was more sustained among children without severe developmental delay compared to children with severe developmental delay.Interpretation: More than half of these children with community acquired septic shock experienced at least a 10% improvement in HRQL from baseline to 3 months. Children with severe developmental delay did not sustain this improvement at 12 month follow-up.

Accuracy of SOFA Score to Predict Outcome in Community-Acquired Sepsis

Background: The new definition of Sepsis-3 defines sepsis as life-threatening organ dysfunction, demonstrated by an increase in the Sequential Organ Failure Assessment (SOFA) of 2 or more points, caused by a dysregulated host response to infection. The performance of SOFA score data in a setting of a tertiary public hospital in a middle-income country remains limited. Objective: To determine the accuracy of the SOFA score to predict the 28-day mortality in community-acquired sepsis patients. Materials and Methods: A retrospective study enrolled community-acquired sepsis and septic shock patients admitted between January and December 2015 in Hatyai Hospital, a tertiary public Hospital in Southern Thailand. All variables for calculating the SOFA and qSOFA scores were collected. The primary outcome was the 28-day mortality. Results: Three hundred seventy-nine patients were enrolled. Eighty-seven patients (23%) died. The median (IQR) SOFA score was 6 (3, 9) points. The SOFA score had a fair predictive performance (AUROC 0.71, 95% CI 0.65 to 0.77), which was higher than qSOFA score (AUROC 0.67, 95% CI 0.62 to 0.73). The SOFA score of 2 points associated with mortality (13%) and higher score patients had an incremental increase mortality rate. The hazard ratio (HR) was 4.59 (95% Cl 1.3 to 15.78, p=0.02) for SOFA Score 6 to 7 points. Conclusion: Among patients presenting with community-acquired infection, the SOFA score indicated the fair predicting ability for the 28-day mortality and performed better than qSOFA score. Keywords: SOFA, qSOFA, Sepsis, Accuracy, Mortality, Community-acquired infection, Thailand

515: Improvement in Health-Related Quality of Life After Community-Acquired Pediatric Septic Shock

515: Improvement in Health-Related Quality of Life After Community-Acquired Pediatric Septic Shock

Health-Related Quality of Life After Community-Acquired Septic Shock in Children With Preexisting Severe Developmental Disabilities.

To serially evaluate health-related quality of life during the first year after community-acquired septic shock in children with preexisting severe developmental disabilities and explore factors associated with health-related quality of life changes in these children. Secondary analysis of the Life after Pediatric Sepsis Evaluation investigation. Twelve academic PICU in the United States. Children greater than or equal to 1 month and less than 18 years old identified by their family caregiver (e.g., parent/guardian) as having severe developmental disability prior to septic shock. Family caregivers completed the Stein-Jessop Functional Status II-R Short Form as a measure of their child's health-related quality of life at baseline (reflecting preadmission status), day 7, and months 1, 3, 6, and 12 following PICU admission. Stein-Jessop Functional Status II-R Short Form scores were linearly transformed to a 0-100 scale, with higher scores indicating better health-related quality of life. Of 392 Life after Pediatric Sepsis Evaluation participants, 137 were identified by their caregiver as having a severe developmental disability. Sixteen children (11.6%) with severe disability died during the 12 months following septic shock. Among 121 survivors, Stein-Jessop Functional Status II-R Short Form scores declined from preadmission baseline to day 7 (70.7 ± 16.1 vs 55.6 ± 19.2; p < 0.001). Stein-Jessop Functional Status II-R Short Form scores remained below baseline through month 12 (59.1 ± 21.0, p < 0.001 vs baseline). After adjusting for baseline Stein-Jessop Functional Status II-R Short Form, the caregiver being a single parent/guardian was associated with lower month 3 Stein-Jessop Functional Status II-R Short Form scores (p = 0.041). No other baseline child or caregiver characteristic, or critical illness-related factors were significantly associated with month 3 Stein-Jessop Functional Status II-R Short Form scores. Health-related quality of life among children with severe developmental disability remains, on average, below baseline during the first year following community-acquired septic shock. Children with severe disability and septic shock that are in single parent families are at increased risk. Clinical awareness of the potential for decline in health-related quality of life among disabled children is essential to prevent this adverse outcome from being missed.